Complications in Posterior Cranial Vault Distraction.

BACKGROUND: The use of posterior cranial vault distraction for the treatment of elevated intracranial pressure is gaining popularity and is a standard for first-stage cranial expansion in syndromic craniosynostosis at many institutions. However, although the operation is faster and less complex than other cranial vault remodeling procedures, it is not without its own unique set of complications. METHODS: We surveyed the published literature for case series and case control studies on posterior vault distraction. Complication rates and types for these series were tabulated and grouped by management. When outcomes were unclear, corresponding authors were contacted for clarification and treatment plans. RESULTS: Eleven reports were found from a search of all the literature on posterior cranial vault distraction with a range of 1 to 22 included patients. The average age at surgery was 16.2 ± 11.8 months. Complication rates ranged from 12.5% to 100%, with the average of 30% of patients across all studies. The most common complications reported were cerebrospinal fluid leak or dural injury, followed by wound infections or device exposures, and device failure. There were no reported patient deaths or long-term morbidities. CONCLUSIONS: Posterior cranial vault distraction is a relatively safe and effective therapy for the treatment of elevated intracranial pressure in the setting of syndromic craniosynostosis. The majority of described complications center on the interaction of the device with the dura, device extrusion, and infection. Extreme care must be used with the placement of these distraction devices and with handling of the dura at the osteotomy sites to ensure successful outcomes and avoid complications. LEVELS OF EVIDENCE: III.

Neurocutaneous melanosis is associated with tethered spinal cord.

PURPOSE: Neurocutaneous melanosis (NCM) is a rare congenital disorder occurring in children born with multiple or large congenital melanocytic nevi (CMN) in association with melanocytic deposits in the leptomeninges. Multiple associations between NCM and other syndromes or neurologic abnormalities have been reported. Of note, there exists a possible association between NCM and tethered cord (TC). METHODS: We retrospectively reviewed charts and films of all patients with the diagnosis of NCM at the Children's Hospital of Pittsburgh (CHP) from August 2002 to present. RESULTS: Five children met the criteria for NCM at our institution over a 12-year period. Apart from the melanocytic deposits, one or more additional spinal abnormalities were identified in all children. Three children had radiographic evidence of a low-lying conus medullaris, two of which also demonstrated lipomatous infiltration of the filum terminale, consistent with a tethered cord (TC). CONCLUSIONS: Clinical features of NCM include dermatologic and neurologic manifestations. To date, this is the first series to note an association between NCM and TC. While nearly all recent series of NCM patients advocate early MRI of the neuroaxis, we recommend screening imaging of the spine on children with possible NCM regardless of the locations of CMN.

Ventricular access devices are safe and effective in the treatment of posthemorrhagic ventricular dilatation prior to shunt placement.

Intraventricular hemorrhage of prematurity (IVH) is a diagnosis that has become more frequent in recent years. Advances in medical care have led to survival of increasingly premature infants, as well as infants with more complex medical conditions. Treatment with a ventricular access device (VAD) was reported almost 3 decades ago; however, it is unclear how effective this treatment is in the current population of premature infants. At our institution (from 2004 to present), we treat posthemorrhagic hydrocephalus (PHH) with a VAD. In order to look at safety and efficacy, we retrospectively combed the medical records of premature children, admitted to Lucile Packard Children's Hospital from January 2005 to December 2009, and identified 310 premature children with IVH. Of these, 28 children required treatment for PHH with a VAD. There were no infections associated with placement of these devices and a very low rate of other complications, such as need for repositioning (7.41%) or replacement (3.75%). Our data show that treatment with a VAD is very safe, with few complications and can be used to treat PHH in this very complex infant population.

CyberKnife stereotactic radiosurgery for the treatment of intramedullary spinal cord metastases.

Spinal cord intramedullary metastases are uncommon and treatment options are limited. We reviewed our experience treating these lesions with radiosurgery to assess safety and efficacy, and to define preliminary treatment recommendations. With Institutional Review Board approval, we identified nine patients with 11 metastases treated with radiosurgery at Stanford University Hospital, between 2000 and 2010. We also reviewed all available published series discussing the treatment of spinal cord metastases. Our patients ranged in age from 33 years to 77 years (median 63 years) and included seven women and two men. Tumors ranged in size from 0.12 cm(3) to 6.4 cm(3) (median 0.48 cm(3)). Five were from breast cancer, two were non-small cell lung cancers, one was a cystic adenocarcinoma, and one was from an epithelioid hemangioepithelioma. All patients had neurologic deficits and multiple other metastases. We delivered 14 Gy to 27 Gy (median 21 Gy) in one to five (median 3) fractions. Complete follow-up was available for all nine patients. One patient remains alive 14 months after therapy. Of the eight deceased patients, survival ranged from one month and two days to nine months and six days (median four months and four days). There were no local recurrences or worsened neurological deficits. To our knowledge this is the largest reported series of spinal cord intramedullary metastases treated with radiosurgery. Survival was poor due to systemic disease, but radiosurgery appears to be safe and prevented local recurrences. With fewer sessions than conventional radiation and less morbidity than surgery, we feel radiosurgery is appropriate for the palliative treatment of these lesions.

Epilepsy surgery following brain tumor resection in children.

OBJECT: Intractable epilepsy following successful brain tumor surgery in children may have several underlying causes such as residual tumor, cortical dysplasia, and gliosis. The authors reviewed the cases of children who had previously undergone resection of a brain tumor only to have medically refractory seizures postoperatively. METHODS: The authors performed a retrospective case review of 9 children who underwent brain tumor surgery 2-13 years before undergoing a second surgery to try and control their seizures. RESULTS: Eight of 9 children had seizures at the time of tumor presentation. Tumor types included ganglioglioma, dysembryoplastic neuroepithelial tumor, pilocytic astrocytoma, oligodendroglioma, ependymoma, and choroid plexus papilloma. All patients achieved a seizure-free interval before intractable seizures recurred. After the second operation, 3 children were seizure free, 1 only had auras, 2 had rare complex partial seizures, and 3 continued to have relatively frequent seizures, although the frequency and severity were reduced. Seven of 9 patients had pathology showing residual tumor. CONCLUSIONS: Epilepsy surgery following earlier brain tumor surgery can provide substantial benefit with reduced seizure number and severity. Despite reassuring brain imaging results, residual tumor was present more often than expected in pathological specimens.